PBS Broadcast Angers Chiropractors

Stephen Barrett, M.D.

Well-reasoned criticism of chiropractic quackery has triggered
an angry response from the profession. The criticism took place
during a segment ("Adjusting the joints") of Scientific
American Frontiers (SAF) that was broadcast beginning June 4th
on Public Broadcasting System stations throughout the country.and
can
be viewed on the SAF Web site. The program acknowledged that
spinal manipulation might be useful for acute low back pain [1].
But it also noted that chiropractic's basic theory is nonsense
and that neck manipulation can be dangerous. The parts that upset
the chiropractors are summarized on the SAF Web site:

Invented by Daniel Palmer in 1895, chiropractic aims to correct
blocked nerves—what Palmer claimed were the cause of all disease
—by re-aligning the spine. But as former chiropractor John
Badanes tells Alan [Alda], chiropractic has no basis in anatomy.
Conducting a typical examination, Badanes explains how patients
and chiropractors alike can misinterpret the popping sound that
accompanies spinal adjustments. In fact it's dissolved gas being
released in the joint fluid (the same thing that happens when
you crack your knuckles) and not a sign that vertebrae are changing
position—an anatomical impossibility.

Like Badanes, physician Robert Baratz, [president] of the
National Council Against Health Fraud, takes issue with chiropractic.
Baratz is concerned about the risk of injury during neck manipulation,
which can place severe strain on a vertebral artery, leading
to blood clotting and stroke. Although chiropractors maintain
this type of injury is very rare, a recent Canadian study estimated
that 20 percent of all strokes caused by artery damage could
be a result of neck manipulation. That figure translates into
more than 1,300 strokes a year in the United States [2].

Chiropractors almost never accept or react constructively to
criticism. When specific wrongdoings are exposed, they typically
claim that their critics are biased, the criticism is unbalanced,
and that the medical profession does things that are much worse.
Within three days, the two largest chiropractic groups did exactly
that and urged their members to flood PBS officials with protest
messages [3,4].

The ACA Protest

On June 7, the American Chiropractic Association's president
sent letters to PBS officials which said (in part):

I find it ironic that a program titled "Scientific American
Frontiers" would completely ignore the scientific foundation
of the chiropractic profession. The chiropractic portion of the
June 4 episode titled "A Different Way to Heal?" irresponsibly
characterized chiropractic care—a legitimate, research-based
form of health care—as a fraudulent hoax.

I am also disappointed that you chose a group of admitted
chiropractic antagonists, representatives of the National Council
Against Health Fraud (NCAHF), as your "expert" health
care sources. The NCAHF Web site describes chiropractic as "America's
homegrown health care cult."1 The producers of your program
could not have expected objectivity from this organization. And
as a viewer of public television, I expect more reliable information
than what the program offered.

I must also take you to task on the format of the program
itself. The program did not offer any of your pro-chiropractic
guests an opportunity to rebut the foolish statements made by
the NCAHF group and former doctor of chiropractic John Badanes.
This would be the legal equivalent to a jury trial in which the
plaintiff's attorney is the only counsel permitted to make a
closing statement to the jury. Secondly, through just a little
research, you would have learned that an ACA representative would
make the most logical pro-chiropractic guest for the program.
Excluding the nation's largest chiropractic organization from
the discussion is irresponsible. . . .

A more balanced segment would have featured representatives
from the ACA and the scientific community discussing the numerous
studies throughout the world that have shown chiropractic care
to be effective and safe for a variety of conditions. Instead,
the program's aim clearly appeared to be to discredit chiropractic,
with NCAHF operating as a more-than-willing partner. . . .

During the program, Robert Baratz of NCAHF errantly claimed
that there is no scientific basis for chiropractic care. This
is simply not true. . . .

Your program also failed to cite any of the countless examples
of chiropractic's successful integration into today's health
care system. . . .

Despite such convincing evidence, some organizations such
as NCAHF continue to question the legitimacy of chiropractic
and other forms of alternative medicine. . . .

Far too many patients—young and old—have their pain
treated with medication that may have side effects that do not
correct the underlying source of their problem.

The ACA believes that patients have the right to know about
the health risks associated with any type of treatment, including
chiropractic. However, health care consumers should be aware
that the risks associated with chiropractic treatment are infinitesimally
low.

Finally, we are particularly concerned that your biased, misleading
and malicious attack has severely and wrongfully damaged the
reputation of the chiropractic profession and chiropractic colleges.
We urge that you reconsider the assertions made in your program
given the damaging effects they have had on the profession and
on these institutions, and that you publicly withdraw the assertions
with an apology to this association and to the nation's chiropractic
colleges [4].

The ICA Protest

The International Chiropractors Association called for "an
immediate and universal response from the chiropractic community
to protest the on-going broadcast of a grossly distorted and internationally
damaging depiction of the science and practice of chiropractic."
Its message, posted to the group's Web site, stated (in part):

This program is supposedly looking at alternative approaches
to health care. It is clear, however, that the producers were
anything but objective when gathering their material. Both the
script and the clips included are designed to distort the public's
understanding of chiropractic in a most negative and damaging
way.

In the broadcast that first aired on June 4th, hosted by well-known
celebrity Alan Alda, chiropractic is represented as being unscientific,
religion-based and extremely dangerous, all representations which
are insulting and damaging to the 55,000 doctors of chiropractic
who are licensed doctor-level health care providers and the millions
of patients who are under their care. The producers of this show
made an obvious decision to seek out chiropractic's most virulent
critics, presenting their assertions as fact, and characterizing
the few positive aspects of chiropractic noted in the show, such
as the enthusiastic testimonial of a patient, as unreliable and
lacking in validity.

"It is crystal clear that from start to finish, the objective
of this production was to project the most negative picture of
chiropractic possible," said ICA President Dr. D.D. Humber.
"The carefully crafted, demeaning language, the complete
distortion of the most basic facts about chiropractic and the
absence of any reference to any of the landmark elements of chiropractic's
validity, from state licensure and Medicare inclusion to any
of the hundreds of studies that provide compelling evidence of
chiropractic's effectiveness, reveal the editorial mission of
this production." . . .

"The outrage that chiropractors have every right to feel
at the scurrilous and deceitful attack through this broadcast
must be compounded by the knowledge that it is our money that
is being used to perpetrate this injustice," said Dr. Humber.
ICA also urges every concerned citizen to make sure as part of
any communication with local PBS stations to let them know of
the economic impact this incident will have. The ICA is calling
on the 55,000 doctors of chiropractic in the U.S., the 100,000
others they employ, chiropractic students and the tens of millions
of people of all ages to whom doctors of chiropractic effectively
and safely provide care, to withhold all donations until PBS
corrects the damage it has done to a worthy and noble profession.
ICA also urges the chiropractic community to let their state
legislative representatives and Members of Congress know how
they feel about the abuse of the public trust displayed by PBS
in this damaging broadcast. PBS holds a tax-exempt status as
well as receiving hundreds of millions of dollars in taxpayers'
money. . . . [4].

SAF's Response

On June 11, SAF's producers issued the following response:

The Scientific American Frontiers episode, "A Different
Way to Heal" set out to examine some widely used approaches
to health care in the rapidly expanding field of alternative
medicine. The aim throughout the program was to ask what science
has to say about these alternative approaches and their respective
underlying theories.

The segment entitled "Adjusting the Joints" explored
the subject of chiropractic as a healing art and science. The
segment delved into the origin and theory of chiropractic, presented
a number of specific techniques via trained chiropractors and
their patients, and raised questions about some aspects of chiropractic,
including evidence for the underlying principle of "subluxations"
and the connection between spine alignment and health, methods
of diagnosis, and the safety of certain forms of neck adjustment.

The segment did not claim that chiropractic is fraudulent
and did not attempt to prove or disprove that chiropractic "works,"
but it does state that chiropractic has no basis in science.
This conclusion is entirely justified by both current research
and generally accepted views of human anatomy.

The underlying principle of chiropractic theory is that there
is a direct association between the shape of the spine (the alignment
of the vertebrae and the spine's curvature) and disease. Chiropractors
claim that health problems can be caused by "subluxations,"
or blockages of nerve energy, which are caused by malpositioned
vertebrae. By "adjusting" vertebra- manually exerting
force on the spine so as to physically displace parts of the
skeleton-chiropractors say they are removing the subluxation
and hence allowing the body to heal itself. We felt it was important
to review the scientific evidence for the existence of subluxations,
as defined by chiropractors. We reviewed the scientific literature,
with the guidance of a number of qualified medical sources, and
concluded that there was no such evidence available in any form
which would meet generally accepted scientific standards. On
the contrary, there is scientific literature failing to find
subluxations and associated phenomena stretching back thirty
years, as was noted in the program.

Some viewers commented that the story was biased against chiropractic.
We made a serious effort to give the chiropractic profession
the opportunity to present their own case. Those in the segment
supporting chiropractic included: the president of one of the
most established and best-known chiropractic colleges in the
country; three experienced and fully licensed Doctors of Chiropractic
demonstrating and explaining in detail three different widely
used techniques; and a patient who expressed her satisfaction
with chiropractic treatment. To counter those five pro-chiropractic
individuals we presented two individuals critical of chiropractic:
a medical doctor and a former Doctor of Chiropractic who practiced
for many years and who taught at a major chiropractic college.
We allowed each of the individuals included, both pro and con,
to express their own opinions. Other factual information conveyed
in the segment included direct quotations from Daniel Palmer,
the founder of chiropractic, and references to specific published
papers in the medical literature.

Other viewers commented that the program ignored positive
studies on chiropractic and included only negative studies. While
it's true that there are many studies which purport to show the
benefits of chiropractic, there are in fact very few which were
conducted to the highest scientific standards. In reviewing research
on chiropractic we held papers to those standards and looked
for rigorous, well-designed studies that appeared in solid, peer-review
medical journals. Our advisor in analyzing studies on chiropractic
was Dr. Wally Sampson, a retired Stanford Medical School professor
and editor of The Scientific Review of Alternative Medicine.
In that high-quality category there are in fact very few positive
papers supporting benefits of chiropractic for particular health
problems. The one area where there is significant published evidence
of chiropractic benefit is in treating back pain. Valid studies
have shown that chiropractic can be of benefit to back pain sufferers.
However, chiropractic success rates were no greater than conventional
approaches like physical therapy and exercise. Since many chiropractors
use procedures that are similar to those of conventional therapies,
which do not require any belief in theories of subluxation and
spinal displacement, the back pain studies cannot be used to
validate chiropractic theory. Because we felt the subject of
chiropractic and back pain was likely to be of importance for
many viewers, we created an expanded discussion of the subject
on the the Scientific American Frontiers Web site with the feature
entitled "Keeping the Spine in Line."

On the question of chiropractic neck adjustments and stroke,
some viewers questioned the statistics we used and expressed
concern that stroke risk was exaggerated. Referring to a recent
Canadian study, what we said was, "20% of all strokes caused
by artery damage could be a result of neck manipulation. That
translates into more than 1300 strokes a year in the US."
We used the phrase "artery damage" to substitute for
the technical term "vertibrobasilar dissection." That
being said, our narration was a precise and accurate representation
of the study in question. Other viewers wished that we had cited
more studies on the stroke question. Indeed, we could have if
not for time constraints. One British study we would have liked
to discuss looked carefully at the question of under-reporting
surrounding stroke and neck manipulation. In the study, neurologists
who routinely treat stroke emergencies were first surveyed to
see if they ever asked patients if they'd had a chiropractic
neck manipulation recently. It was found that neurologists did
not ask, as a rule. Then the neurologists were instructed to
ask their patients as a matter of course. The incidence of chiropractic-related
stroke shot up. So this wasn't just under-reporting that the
study revealed - more like zero reporting. It seems that patients
and neurologists have not been making connections between events
which, of course, may well be days apart. The question of under-reporting
- or more accurately of simply missing cause and effect - discussed
in the Canadian study as well, is clearly now beginning to get
more attention in academic circles.

In summary, we believe "Adjusting the Joints" was
fair, accurate and balanced and, in conjunction with the other
segments of "A Different Way to Heal" contributed to
a more informed public understanding of a significant trend in
health care today [5].

The Bottom Line

Scientific American Frontiers and its producers did an excellent
job of placing chiropractic in proper perspective. As far as I
know, the program was the first national television show in which
chiropractic's subluxation
theory was appropriately debunked. I am very pleased to see
that chiropractic's knee-jerk reaction has not intimidated SAF's
producers.